About this opportunity
Quantdynamicss lists this Medical Director (Utilization Management) (#25-05424) opportunity in nevada, Iowa. Review the employer’s description below for duties, qualifications and application requirements.
Job description
Description: The Medical Director (Utilization Management) plays a critical role in leading and supporting the clinical integrity of the utilization management function, with a specific focus on inpatient and post-acute care reviews. This physician leader ensures timely and appropriate care determinations for Medicare Advantage members, guided by clinical criteria, CMS regulations, and evidence-based practices.
Reporting to the Chief Medical Officer, this role focuses on evaluating medical necessity and appropriateness of hospital admissions, continued stays, and post-acute services. The Medical Director collaborates with care management teams, providers, and internal stakeholders to ensure care decisions support optimal outcomes, cost-efficiency, and regulatory compliance.
Requirements
Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings (e.g., SNF, IRF, LTACH, home health) for Medicare Advantage members
Assess appropriateness of acute care services using evidence-based guidelines (e.g., MCG, InterQual) and CMS criteria
Serve as the physician reviewer for escalated or complex UM cases requiring medical judgment
Collaborate with utilization management and care management teams to ensure consistent, clinically appropriate, and cost-effective care
Participate in peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care
Identify trends in care utilization and support the development of interventions to reduce unnecessary admissions or extended stays
Provide input into the development and implementation of medical policy and UM protocols
Support CMS regulatory compliance, audit preparedness, and delegated oversight for UM functions
Contribute clinical expertise to quality improvement initiatives related to utilization patterns, readmission reduction, and transitions of care
Document all reviews and decisions according to NCQA, CMS, and organizational requirements
Participate in UM committee meetings and represent the health plan in external provider and stakeholder engagements as needed
About the Company
Quant Dynamics Solutions is consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
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Worksite address
nevada, IA, 50201, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.